of Vancouver General Hospital. Prepared by the Pharmaceutical Sciences Clinical Services Unit by authority of the Drugs & Therapeutics Committee and the Medical & Academic Advisory Committee.

Restricted Administration Drug Tables

Some drugs are restricted as to who may administer them, under which circumstances and in which nursing areas.

The restrictions apply for one or more of the following reasons:

a) possibility of severe, immediate reaction (eg. hypotension)
b) a variable dose, dependent on patient's response
c) a narrow therapeutic :  toxic ratio
d) possibility of extravasation and tissue sloughing and necrosis
e) diagnostic use
f) infrequent use

A. MEDICATIONS NOT TO BE ADMINISTERED BY THE DIRECT INTRAVENOUS ROUTE.

Acetylcysteine
Acyclovir
Alcohol, ethyl
Alemtuzumab
Alprostadil
Amikacin
Amphotericin B
Amphotericin B liposomal
Amsacrine
Anti-thymocyte globulin (equine)
Anti-thymocyte globulin (rabbit)
Azithromycin
Basiliximab
Carboplatin
Carmustine
Caspofungin
Ciprofloxacin
Cisplatin
Cladribine
Clindamycin
Clodronate
Cotrimoxazole
Cyclosporine
Daclizumab
Deferoxamine
Desmopressin
Dobutamine
Dopamine
Epoprostenol
Erythromycin
Etoposide
Filgrastim
Fluconazole
Fludarabine
Fomepizole
Foscarnet
Ganciclovir
Gentamicin
Hydrochloric acid
Imipenem-Cilastatin
Iron Dextran
Iron Sucrose
L-asparaginase
Lipids, intravenous
Levofloxacin
Melphalan
Methotrimeprazine
Metronidazole
Mithramycin
Moxifloxacin
Multiple vitamin infusion (MVI)
Mycophenolate
Nitroprusside
Norepinephrine
Pamidronate
Penicillin G Sodium
Piperacillin-tazobactam
Potassium acetate
Potassium chloride
Potassium acid phosphate
Protein C, activated
Rituximab
Salbutamol
Sodium acetate
Sodium phosphate
Streptokinase
Streptomycin
Tacrolimus
Teniposide
Ticarcillin-clavuanate
Tirofiban
Tobramycin
Trace element solution
Vancomycin
Vasopressin
Vitamin B complex
Voriconazole

B. SPECIAL AND CRITICAL CARE AREAS

THE FOLLOWING MEDICATIONS MAY BE ADMINISTERED VIA THE DIRECT INTRAVENOUS ROUTE BY NURSES IN SPECIAL AND CRITICAL CARE AREAS ONLY (i.e. in general nursing units the administration of these medications by the direct IV route must be performed by the physician).

Abciximab***
Adenosine****
Alteplase***
Amiodarone
Argatroban
Atropine *, **
Calcium chloride
Calcium gluconate
Chlorpheniramine
Chlorpromazine *
Cisatracurium***
Darbepoetin
Diltiazem **
Edrophonium
Ephedrine
Epinephrine*****
Eptifibatide***
Erythropoietin
Glycopyrrolate
Hydralazine **
Hyoscine butylbromide
Ketorolac
Labetalol
Lidocaine **
Neostigmine
Pancuronium***
Pentobarbital
Phenobarbital
Phentolamine
Phenylephrine***
Procainamide **
Prochlorperazine *
Promethazine
Protamine
Rocuronium***
Scopolamine hydrobromide
Sodium bicarbonate
Succinylcholine***
Tenecteplase***
Verapamil **
Vitamin K-1

* These medications may be administered by the direct IV route by nurses in the Palliative Care Unit.

** These medications may be administered by the direct IV route by nurses in the Telemetry unit; a physician MUST administer the first IV direct dose of verapamil and diltiazem

*** Restriced to Critical Care Areas as listed in the individual monographs

****Nuclear technologist may also administer under the direct supervision of a physician

*****Cardiac Sciences (C10AB, CD) may also administer by direct IV route

 

C. THE ADMINISTRATION OF THE FOLLOWING MEDICATIONS BY ALL PARENTERAL ROUTES MUST BE PERFORMED BY THE PHYSICIAN.

Alfentanil
Aspergillus Skin test²
Botulinum toxin
Bupivacaine³
Candida Skin test²
Carboprost¹
Chloroprocaine
Dantrolene
Dipyridamole⁴
Histamine
Indigotindisulfonate sodium
Methylprednisolone acetate⁶
Mivacurium
Propofol⁵
Remifentanil
Ropivacaine³
Sodium Tetradecyl
Sufentanil
Trichophyton skin test²
Tuberculin skin test²

¹Nurses may administer via bladder instillation

²TB units, Employee Health Centre, and UBC Hospital may administer where the nurses have been trained to administer and interpret the test

³nurses may administer via continuous epidural infusion and PICRA

⁴may be administered by nuclear medicine cardiac specialist nurse or by nuclear medicine technologist under supervision of a physician

⁵CSICU nurses may titrate IV infusions downward post cardiac surgery; ICU nurses may administer for refractory agitation in ventilated patients; Emerg nurses may administer IV direct if ED physician at bedside

⁶nurses may administer intramuscular (IM)

D. THE ADMINISTRATION OF THE FOLLOWING MEDICATIONS BY THE DIRECT IV ROUTE MUST BE PERFORMED BY THE PHYSICIAN.

Aminophylline¹
Aprotinin
Atracurium
Colistin
Digoxin Immune Fab
Droperidol²
Enoxaparin
Esmolol
Flumazenil⁶
Fluorescein³
Haloperidol⁷
Indocyanine-Green
Isoproterenol
Ketamine⁵
Magnesium Sulphate
Mannitol
Methylene blue
Midazolam⁴
Milrinone
Oxytocin
Papaverine
Sincalide¹
Tranexamic acid

¹Nuclear technologist may administer under direct supervision of a physician

²Nurses in PAR may administer by direct IV route.

³Nurses in the EYE CARE CENTRE may administer under supervision of a physician.

⁴Nurses in Restricted areas of use (refer to monograph) may administer by direct IV route.

⁵In ICU a nurse may give ketamine by direct IV to patients already mechanically ventilated after initial dose has been given by a physician.

⁶Emergency nurses may administer direct IV

⁷Nurses in critical care areas and burn unit may administer direct IV

E. THE FOLLOWING MEDICATIONS MAY BE ADMINISTERED BY THE DIRECT IV ROUTE BY NURSES IN SPECIAL AND CRITICAL CARE AREAS. NURSES IN GENERAL NURSING UNITS MAY ADMINISTER THESE DRUGS BY THE DIRECT IV ROUTE, PROVIDED THAT A VENOUS ACCESS HAS BEEN ESTABLISHED AND ACCORDING TO POLICIES AND RECOMMENDATIONS STATED IN THIS MANUAL.

Ampicillin
Ascorbic acid
Azathioprine
Benztropine
Cefazolin
Cefotaxime
Ceftazidime
Ceftriaxone
Cefuroxime
Chloramphenicol
Cloxacillin
Cosyntropin
Danaparoid
Dexamethasone
Dextrose 50%
Diazepam
Diazepam in emulsion
Digoxin
Dihydroergotamine
Dimenhydrinate
Diphenhydramine
Dolasetron
Estrogens, conjugated
Ethacrynic acid
Fentanyl**
Folic Acid
Furosemide*
Glucagon
Gonadorelin acetate
Heparin
Hydrocortisone
Hydromorphone
Insulin, regular
Levothyroxine
Lorazepam
Meperidine
Methylprednisolone (Solu-Medrol)
Metoclopramide
Metoprolol **
Morphine
Naloxone
Octreotide
Ondansetron
Pantoprazole
Phenytoin
Piperacillin
Propranolol **
Protirelin
Pyridoxine
Ranitidine*
Thiamine
Vitamin B-12

*nuclear technologists may administer under supervision of a physician

**See monograph

F. IN ADDITION TO THE DRUGS IN TABLE E, THE FOLLOWING DRUGS MAY BE ADMINISTERED BY DIRECT IV ROUTE BY NURSES IN THE PALLIATIVE CARE UNIT, PROVIDED THE VENIPUNCTURE HAS BEEN ESTABLISHED AND ACCORDING TO POLICIES AND RECOMMENDATIONS IN THIS MANUAL.

Atropine
Chlorpromazine
Prochlorperazine
Scopolamine hydrobromide

G. CYTOTOXIC AGENTS:

1. Cytotoxic agents are classified as antineoplastic agents (vesicant and non-vesicant) and non-antineoplastic agents.

2. Registered nurses on all units must be knowledgeable about the medication and the safe handling procedures cited in Patient Care Guideline C-396 Cytotoxic Standards prior to administering any cytotoxic agent.

3. Administration of all antineoplastics via peripheral or cental route is restricted to nurses who have been specially trained and certified.

Level 1 certification allows nurses to administer non-vesicant agents peripherally and non-vesicant and vesicants centrally. Level 2 certification allows nurses to administer vesicant agents peripherally.

4. Administration of vesicant antineoplastic agents via the peripheral route must be given using the side arm method. Exception: administration of vincristine by the peripheral route must be by minibag without a pump. Vesicants which cannot be given via the side arm method must be administered by the central route (ie, amsacrine, busulfan, carmustine, melphalan, mithramycin).

5. Non-antineoplastic agents via the central or peripheral routes may be administered by registered nurses on all units.

ANTINEOPLASTICS:

Vesicant
Amsacrine
Busulfan
Carmustine
Dactinomycin
Daunorubicin
Doxorubicin
Epirubicin
Mechlorethamine
Melphalan
Mithramycin
Mitomycin C
Vinblastine
Vincristine

Non-Vesicant
L-Asparaginase *
Bleomycin *
Bortezomib
Carboplatin
Cisplatin
Cladribine
Cyclophosphamide
Cytarabine
Dacarbazine
Etoposide
Fludarabine
Fluorouracil
Gemcitabine
Ifosfamide
Methotrexate*
Mitoxantrone
Teniposide
Thiotepa

NON-ANTINEOPLASTICS:
Ganciclovir
Azathioprine

* Further restrictions apply, see the drug monograph.

H. THE RATE OF ADMINISTRATION MUST BE CONTROLLED BY AN AUTOMATED INFUSION CONTROL DEVICE WHEN THE FOLLOWING DRUGS ARE ADMINISTERED VIA CONTINUOUS INTRAVENOUS OR INTERMITTENT INTRAVENOUS INFUSION.

Consult individual monographs for complete information.

Abciximab
Alemtuzumab
Alfentanil
Alprostadil
Alteplase
Amiodarone
Aminophylline (Theophylline)
Amphotericin B
Amphotericin B liposomal
Antineoplastics*
Antithymocyte Globulin
Aprotinin
Argatroban
Bivalirudin
Cisatracurium
Cyclosporine
Danaparoid***
Deferoxamine
Diazepam
Diltiazem
Dobutamine
Dopamine
Epinephrine
Epoprostenol
Eptifibatide
Ethyl Alcohol
Fat Emulsion, Intravenous
Foscarnet
Furosemide***
Gemcitabine
Heparin***
Hydralazine***
Insulin, regular
Iron dextran, sucrose
Isoproterenol
Ketamine
Ketorolac***
Labetalol
Lidocaine
Lorazepam***
Magnesium sulphate****
Midazolam
Milrinone
Mivacurium
Naloxone
Narcotic Agents***
Nitroglycerin
Nitroprusside
Norepinephrine
Octreotide***
Oxytocin
Pancuronium***
Phentolamine
Phenylephrine
Phenytoin – doses > 500 mg
Potassium acetate **
Potassium chloride **
Potassium phosphate
Procainamide
Propofol
Propranolol***
Protein C, activated
Remifentanil
Rituximab
Rocuronium
Salbutamol
Sodium Chloride 3%
Sodium Phosphate
Streptokinase
Succinylcholine
Tacrolimus
Thiopental***
Tirofiban
Vancomycin – if pump available
Vasopressin
Verapamil

* Infusions of antineoplastiac agents which are vesicants may only be given via central line. Exception: Administration of vincristine by the peripheral route must be by minibag without a pump.
** Potassium >40 mEq/bag or >20 mEq/hr
***Pump required for continuous infusions only
****Pump required for doses > 2 g or for continuous infusions

I. THE ADMINISTRATION OF THE FOLLOWING MEDICATIONS BY THE SUBCUTANEOUS ROUTE IS RESTRICTED TO THE PALLIATIVE CARE UNIT UNLESS INDICATED OTHERWISE:

Fentanyl - continuous subcutaneous infusion and subcutaneous injection may be given on all nursing units, restricted to Palliative Care and Complex Pain Services

Lidocaine - continuous subcutaneous infusion

Methotrimeprazine - continuous subcutaneous infusion; subcutaneous injections can be administered on any nursing unit

Midazolam - continuous subcutaneous infusion restricted to palliative care service; subcutaneous injections can be administered on any nursing unit authorized to administer this drug

Potassium chloride - continuous subcutaneous infusion ONLY

Rev. May 2008